Work Group Report: COVID-19: Unmasking Telemedicine
2020; Elsevier BV; Volume: 8; Issue: 8 Linguagem: Inglês
10.1016/j.jaip.2020.06.038
ISSN2213-2201
AutoresNathan Hare, Priya Bansal, Sakina Bajowala, Stuart L. Abramson, Sheva K. Chervinskiy, Robert Corriel, David W. Hauswirth, Sujani Kakumanu, Reena Mehta, Quratulain Rashid, M.R. Rupp, Jennifer Shih, Giselle Mosnaim,
Tópico(s)COVID-19 and healthcare impacts
ResumoTelemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape. Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape. AAAAI Position Statements, Work Group Reports, and Systematic Reviews are not to be considered to reflect current AAAAI standards or policy after five years from the date of publication. The statement below is not to be construed as dictating an exclusive course of action nor is it intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. The statement reflects clinical and scientific advances as of the date of publication and is subject to change.For reference only. AAAAI Position Statements, Work Group Reports, and Systematic Reviews are not to be considered to reflect current AAAAI standards or policy after five years from the date of publication. The statement below is not to be construed as dictating an exclusive course of action nor is it intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. The statement reflects clinical and scientific advances as of the date of publication and is subject to change. For reference only. The COVID-19 pandemic led to an unprecedented change in clinical operations, motivating physicians and health care systems worldwide to rapidly implement telemedicine programs to reduce or replace in-person visits.1Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E.W.Y. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol Pract. 2020; 8: 1477-1488.e5Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar Telemedicine has allowed for increased workforce sustainability, limitation of clinician direct exposure to patients, overall reduction of personal protective equipment (PPE) use, and may reduce clinician burnout. It has also facilitated staffing of both large and small facilities that are overwhelmed with pandemic-related patient overload.2Doshi A. Platt Y. Dressen J.R. Mathews B.K. Siy J.C. Keep calm and log on: telemedicine for COVID-19 pandemic response.J Hosp Med. 2020; 5: 302-304Google Scholar In addition, telemedicine has been used for surge control or "forward triage"—the triaging of patients before they arrive in the emergency department (ED). Direct-to-consumer (DTC) visits have allowed patients to be efficiently screened while protecting patients, clinicians, and the community from exposure.3Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for Covid-19.N Engl J Med. 2020; 382: 1679-1681Crossref PubMed Scopus (2086) Google Scholar This rapid need for telemedicine visits has generated the demand to effectively educate allergists/immunologists on how to optimize utilization. Before the pandemic, telemedicine was often reserved for patients with decreased access to care. It is quickly becoming the preferred mode of delivering care for both follow-up and new clinic patients.3Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for Covid-19.N Engl J Med. 2020; 382: 1679-1681Crossref PubMed Scopus (2086) Google Scholar,4U.S. Department of Health & Human ServicesHealth information privacy.https://www.hhs.gov/hipaa/index.htmlDate accessed: May 9, 2020Google Scholar Recognizing telemedicine as a growing field for the practicing allergist/immunologist, the American Academy of Allergy, Asthma and Immunology Health Informatics, Technology and Education (HITE) Committee established a Telemedicine Work Group to review multiple aspects of telemedicine including utility, adoption procedures, billing, security, electronic medical record (EMR) integration, education, and state specific issues. Telemedicine has been shown to decrease costs of travel for patients in both time and money. By making it more convenient for them to obtain care, telemedicine has increased access for patients who might not otherwise be able to receive care or be seen at a given practice.5Shih J. Portnoy J. Tips for seeing patients via telemedicine.Curr Allergy Asthma Rep. 2018; 18: 50Crossref PubMed Scopus (32) Google Scholar,6Dullet N.W. Geraghty E.M. Kaufman T. Kissee J.L. King J. Dharmar M. et al.Impact of a university-based outpatient telemedicine program on time savings, travel costs, and environmental pollutants.Value Health. 2017; 20: 542-546Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar Before the COVID-19 pandemic, patients who may have benefited from telemedicine included poor, elderly, or disabled patients, or those who simply lived too far away to travel for an in-person visit.5Shih J. Portnoy J. Tips for seeing patients via telemedicine.Curr Allergy Asthma Rep. 2018; 18: 50Crossref PubMed Scopus (32) Google Scholar Telemedicine is well suited to large rural states or medically underserved urban areas. A 2019 study found that telemedicine in the Veteran's Health Administration (VHA) has likely improved access to care for veterans who live in rural areas.7Adams S.V. Mader M.J. Bollinger M.J. Wong E.S. Hudson T.J. Littman A.J. Utilization of interactive clinical video telemedicine by rural and urban veterans in the veterans health administration health care system.J Rural Health. 2019; 35: 308-318Crossref PubMed Scopus (46) Google Scholar This convenience is also applicable in emergency and hospital settings where specialists may not be on site. Virtual consultations can limit the need for transportation of ED patients to other facilities for care and hospital transfers.8American Telemedicine AssociationExamples of research outcomes: telemedicine's impact on healthcare cost and quality. April 2013.https://www.amdtelemedicine.com/telemedicine-resources/documents/ATATelemedicineResearchPaper_impact-on-healthcare-cost-and-quality_April2013.pdfDate accessed: May 9, 2020Google Scholar,9ACP HospitalistAdding telemedicine to ICUs in VA hospitals reduced transfers of sickest patients. June 27, 2018.https://acphospitalist.org/weekly/archives/2018/06/27/3.htmDate accessed: May 9, 2020Google Scholar As early as 2007, estimates predicted that teleconsultations could obviate the need for up to 850,000 transfers and save US$537 million dollars per year.8American Telemedicine AssociationExamples of research outcomes: telemedicine's impact on healthcare cost and quality. April 2013.https://www.amdtelemedicine.com/telemedicine-resources/documents/ATATelemedicineResearchPaper_impact-on-healthcare-cost-and-quality_April2013.pdfDate accessed: May 9, 2020Google Scholar A 2016 retrospective study performed in the VHA looking at data from 1997 to 2008 found that, for the clinics studied, the mean no-show rate for doctor appointments was 18.8%. The average cost of a no-show visit in the VHA in 2008 was US$196.10Kheirkhah P. Feng Q. Travis L.M. Tavakoli-Tabasi S. Sharafkhaneh A. Prevalence, predictors and economic consequences of no-shows.BMC Health Serv Res. 2016; 16: 13Crossref PubMed Scopus (188) Google Scholar Telemedicine may help improve patient compliance and decrease the associated financial cost to practices and clinicians of no-show visits by reducing barriers to care.11Portnoy J. Waller M. Elliott T. Telemedicine in the era of COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 1489-1491Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar Cost-benefit analysis data for the use of telemedicine is minimal at this time. However, recent studies conducted in teledermatology and telemedicine in the pre-hospital care setting have recently shown promising results.12Vidal-Alaball J. Garcia-Domingo J. Garcia Cuyas F. Mendioroz J. Flores-Mateo G. Rosanas J. et al.A cost savings analysis of asynchronous teledermatology compared to face-to-face dermatology in Catalonia.BMC Health Serv Res. 2018; 18: 650Crossref PubMed Scopus (24) Google Scholar,13Langabeer II, J.R. Champagne-Langabeer T. Alqusairi D. Kim J. Jackson A. Persse D. et al.Cost-benefit analysis of telehealth in pre-hospital care.J Telemed Telecare. 2017; 23: 747-751Crossref PubMed Scopus (68) Google Scholar Despite the exponential growth of telemedicine in the past 5 years in the United States, the adoption of these services by the allergist/immunologist community was minimal before the pandemic.11Portnoy J. Waller M. Elliott T. Telemedicine in the era of COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 1489-1491Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar Several factors contribute to the rationale for growth of telemedicine during the COVID-19 pandemic. First, the public health emergency (PHE) has led to the development of guidelines for quarantine as well as for social and physical distancing.14Centers for Disease Control and PreventionCoronavirus disease 2019 (COVID-19): community-related exposures. Reviewed March 30, 2020.https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.htmlDate accessed: May 9, 2020Google Scholar The Centers for Disease Control and the Department of Health and Human Services (HHS) have statutory authority to promulgate regulations that protect individuals from communicable diseases, including quarantinable communicable diseases as specified in an Executive Order of the President.15Centers for Disease Control and Prevention, Department of Health and Human ServicesControl of communicable diseases. February 21, 2017.https://www.federalregister.gov/documents/2017/01/19/2017-00615/control-of-communicable-diseasesDate accessed: May 9, 2020Google Scholar A study conducted in late March 2020 by the inspector general of the HHS indicated that hospitals in the United States were desperately short of PPE16U.S. Department of Health & Human ServicesOffice of Inspector General. Hospital experiences responding to the COVID-19 pandemic: results of a National Pulse Survey March 23-27, 2020. April 2020.https://oig.hhs.gov/oei/reports/oei-06-20-00300.pdfDate accessed: May 9, 2020Google Scholar putting health care workers at increased infectious risk. Telemedicine visits have the potential to decrease unnecessary use of PPE and reserve available PPE for hospital use. In addition, it is imperative to continue to treat nonemergent patients outside the hospital to prevent deterioration in their health, as well as to accommodate for the increased demand to care for the sickest coronavirus patients in EDs and intensive care units. Therefore, using telemedicine is ideal for ongoing safe treatment of patients, while continuing to promulgate responsible social and physical distancing in accordance with quarantine regulations in the hopes of slowing the spread of COVID-19. The first step in setting up a telemedicine program is determining the types of patients who will be seen. Assuming that federal, state, malpractice, and insurance guidelines are taken into account, these may include initial consultations, established visits, and patients at a distance. It is important to know the limitations of telemedicine, as there are certain visits that can be challenging to perform through telemedicine. Procedures and procedure-related visits, such as allergy skin tests, immunotherapy and/or biologic injections, and food and/or drug challenges, in general are difficult to accomplish except in the case of a facilitated visit where a trained clinician is present at the patient's site who is adequately trained and is able to accept responsibility for treating the patient if a systemic allergic reaction occurs. The next step is to decide whether the telemedicine visits will be through a synchronous or asynchronous approach. Asynchronous telemedicine is communication with a patient separated by distance and time. Synchronous telemedicine is where the clinician and patient are connected at the same time in a live interactive audiovisual exchange. Synchronous telemedicine is further classified into DTC visits or facilitated visits (FVs). A DTC visit occurs between the patient and clinician at a nonmedical facility, such as the home, where communication is directly through the patient's smartphone or computer. An FV requires a facilitator to operate equipment and guide the patient through the video visit. The equipment needed at the origination (patient) site depends on whether the appointment is an FV, a DTC visit, or a telephone visit. Please refer to this article's Online Repository at www.jaci-inpractice.org for Specific Technology Guidelines. For an FV, there should be a specific room in which the patient can be seen (often a regular examination room). Most origination sites have a "telemedicine cart," which contains the hardware, software, and other equipment needed for a telemedicine visit. For a DTC visit, the only equipment required at the patient's site is what is necessary for video conferencing. This can include a smartphone or a computer with internet, audio, and video capability. The DTC visit should be conducted through a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant platform. However, during the COVID-19 pandemic, the HHS Office for Civil Rights has temporarily decided to "exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies such as FaceTime or Skype" (FaceTime: Apple Inc., Cupertino, CA; Skype: Skype Technologies, Palo Alto, CA).17Centers for Medicare and Medicaid ServicesMedicare telemedicine health care provider fact sheet. March 17, 2020.https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheetDate accessed: May 9, 2020Google Scholar There is no video requirement for a telephone visit, only audio. The third step is determining where the clinician will conduct the visit. For telemedicine visits, the distant site is the location of the clinician while he or she is providing care. The location of the patient at the time he or she is receiving care is termed the originating site. During COVID-19, restrictions have been lifted on where the patient and the clinician can be located for a telemedicine visit to help eliminate barriers to care.17Centers for Medicare and Medicaid ServicesMedicare telemedicine health care provider fact sheet. March 17, 2020.https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheetDate accessed: May 9, 2020Google Scholar Requirements at the distant site include access to a reliable internet connection and adequate privacy to protect patient private health information. Attention should be given by the clinician to lighting, sound, and their surroundings. The clinician should be aware that everything in his or her environment can be seen and heard by the patient. Positioning the clinician's camera to maximize eye contact can provide needed nonverbal communication within the digital platform. If additional family members are present with the patient, establishing their role and connection with the patient is recommended. Once the platform and equipment are in place, the next step is to organize the scheduling of patients. Guidelines for patients best suited for telemedicine should be established. Pre-clinic huddles can be effective forums for identifying patients suitable for telemedicine visits. Initially, consider scheduling the same amount of time for a telemedicine visit as an in-person visit to allow a buffer for technology issues that may come up. Documentation in the EMR can be done at the same time as talking to the patient. The scheduling of telemedicine visits among in-person visits depends on practice efficiency, notification system, and workflow. This can be adjusted as needed. One important aspect to developing a successful telemedicine program is adequate training. Clinicians (and facilitators in the case of FVs) should familiarize themselves with the software and any telemedicine equipment being used ahead of time. It is important to review protocols for coping with software failures and have an easily accessible list of technical support numbers on hand in case there are hardware or software issues. For example, during the COVID-19 pandemic, one may have their primary platform on their HIPAA-secure EMR software. If that fails, one may have a backup, encrypted independent platform. If the first 2 encrypted options fail, traditional phone modalities may be used (see Tables I and II for examples of encrypted and nonencrypted telemedicine platforms, respectively). Flexibility and versatility in dealing with technology failures in real time is paramount.Table IExamples of encrypted telemedicine platforms during the COVID-19 pandemicCharm TelehealthAvailable from: https://www.charmhealth.com/telehealth. Accessed May 9, 2020.DoximityAvailable from: https://www.doximity.com. Accessed May 9, 2020.Doxy.meAvailable from: https://doxy.me/. Accessed May 9, 2020.JotformAvailable from: https://jotform.com. Accessed May 9, 2020.KareoAvailable from: https://www.kareo.com/. Accessed May 9, 2020.MendAvailable from: https://www.mendfamily.com/. Accessed May 9, 2020.Poly (formerly Polycom.Available from: https://www.poly.com/us/en/solutions/industry/healthcare. Accessed May 9, 2020.Secure TelehealthAvailable from: https://securetelehealth.com. Accessed May 9, 2020.TeladocAvailable from: https://www.teladoc.com/. Accessed May 9, 2020.VidyoAvailable from: https://www.vidyo.com/. Accessed May 9, 2020.VseeAvailable from: https://vsee.com/. Accessed May 9, 2020.Zoom—Health Care versionAvailable from: https://zoom.us/healthcare. Accessed May 9, 2020. Open table in a new tab Table IIExamples of nonencrypted telemedicine platforms during the COVID-19 pandemicApple FaceTimeAvailable from: https://apps.apple.com/us/app/facetime/id1110145091. Accessed May 9, 2020.Google HangoutsAvailable from: https://hangouts.google.com/. Accessed May 9, 2020.SkypeAvailable from: https://www.skype.com/en/. Accessed May 9, 2020.Zoom—Free and regular paid versionsAvailable from: https://zoom.us/. Accessed May 9, 2020. Open table in a new tab Providing checklists or a toolkit for a patient that includes educational handouts on the patient's expectations, an introduction to the consent process, how to contact information technology if he or she encounters difficulties during the visit, and how the patient can prepare to ensure a stable digital connection during the visit is essential. Online tools including podcasts and webinars can offer clinicians multiple medical education modalities.11Portnoy J. Waller M. Elliott T. Telemedicine in the era of COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 1489-1491Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar Please see Table III for online resources for telemedicine.Table IIIOnline resources for telemedicineAmerican Medical AssociationTelehealth implementation playbook. Available from: https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook. Accessed May 9, 2020.American Telemedicine AssociationTelemedicine forms. Available from: https://www.americantelemed.org/resource/. Accessed May 9, 2020.American Academy of Allergy Asthma and Immunology Detailed toolkitTelemedicine. Available from: https://www.aaaai.org/practice-resources/running-your-practice/practice-management-resources/telemedicine. Accessed May 9, 2020. COVID-19 billingUtilize telemedicine: how does billing work? Available from: https://education.aaaai.org/resources-for-a-i-clinicians/telemedicine-billing_covid-19. Accessed May 9, 2020. PlatformsTelehealth platforms to consider. Available from: https://education.aaaai.org/resources-for-a-i-clinicians/telehealthplatforms_covid-19. Accessed May 9, 2020.American Academy of PediatricsCoding for telemedicine services. Available from: https://www.aap.org/en-us/Documents/coding_factsheet_telemedicine.pdf. Accessed May 9, 2020.Centers for Medicare and Medicaid ServicesMedicare telemedicine health care provider fact sheet. Available from: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed May 9, 2020.American College of Allergy, Asthma and ImmunologyAvailable from: https://college.acaai.org/practice-management/telehealth-toolkit. Accessed May 9, 2020. Open table in a new tab Clinic schedulers and other staff should contact patients before the visit to discuss preparation for their telemedicine visit. Included in this discussion should be a review of the devices (computer with camera, smartphone, phones, digital tablets) that can be used for the remote telemedicine encounter. In addition, test calls with the device are recommended to ensure that the patient will be able to reliably connect to the clinician for his or her telemedicine visit. Depending on the platform and the health care system involved, consent, required by most states, may be obtained by the clinic staff or clinician and documented before the visit. Even if obtaining a patient consent for telemedicine visits is not required in a particular state, it is an advisable best practice to implement in telemedicine.18The Center for Connected Health Policy National policy: informed consent. 2020.https://www.cchpca.org/telehealth-policy/informed-consentDate accessed: May 9, 2020Google Scholar A telemedicine visit starts when the patient logs into the telemedicine site. Some EMRs have an integrated telemedicine application, thereby eliminating the need for a separate telemedicine application. However, this is not a requirement; the telemedicine and EMR applications do not have to be linked. Once a connection with the patient has been established and consent obtained, the encounter can start. It may be helpful to have the patient's chart in the EMR open, either on the same screen or on a separate screen, to refer to and facilitate documentation during the visit. The clinician may want to discuss what to do if the call drops or internet access is disrupted with the patient at the start. Documenting information from the patient as to his or her current location and phone number is recommended as it can be used to contact emergency medical services if an emergency occurs during the telemedicine visit or if the connection with the patient is lost. The clinician should then conduct the history as he or she would for an in-person visit. After the history has been obtained, a physical examination is performed. The depth of the physical examination depends on the location of the patient. If the patient is at a medical facility, the physical examination can be performed with the use of peripheral equipment (eg, electronic stethoscope and otoscope) and the facilitator. If it is a DTC visit, a physical examination can still be performed, with the clinician guiding the patient to maneuver certain aspects for visualization. As expected, the telemedicine examination is not as comprehensive as compared with an in-person examination. However, it is not as limited as one might expect. With a little creativity, the clinician can still obtain a fair amount of useful data from the telemedicine examination (see Table IV for example telemedicine physical examination pearls). After the physical examination and medical decision making, an assessment and plan are formulated. It is necessary to write orders, give prescriptions, and provide instructions to the patient to conclude the visit. Please see Table V for an overview of the Steps for Conducting a Telemedicine Visit.Table IVExample telemedicine physical examination with E/M billing guidanceExample physical examination: VS: T 98.5 F Wt. 180 pounds BP 126/75 HR 65Constitutional: Appears healthy, alert, cooperative, oriented, and in no acute distressHead: Normocephalic and atraumaticEyes: Conjunctivae/corneas clear, without redness or drainageNose: External nose normal, no drainagePulmonary/chest: No tachypnea, no retractions, no cyanosisNeurological: Grossly normal without focal findings based on what could be seenSkin: Skin color normal. No rashes or lesions visiblePsychiatric: Normal mood and affect. Behavior is normalAdditional examination items possible with: Patient assistance Extra equipment at home (eg, Peak Flow Meter) Smart phone applications with modifications and/or digital telemedicine equipment Wearables (eg, ECG)Tips for obtaining vital signs: Temperature: Patients can take it themselves Blood pressure: Patients can check it if they have the equipment Heart rate: Patients can count it if taught how to do so or use a smart watch Respirations: Patients or the clinician can count it Oxygen saturation: Patients can check it if they have a pulse oximeter at home Weight: Patients can weigh themselvesTips for examining other organ systems: Ear examination: Can be performed with a smart phone app and otoscope attachment, or digital telemedicine otoscope Sinus tenderness: Patients can be taught self-palpation Oropharynx: Use the patient's flashlight Lymph node examination: Patients can be taught self-palpation Heart and/or lung examination: Can be performed with a digital telemedicine stethoscope Abdominal examination: Patients can be taught self-palpation Extremities: Can observe if any clubbing, cyanosis, or edemaE/M billing guidance: All other things being equal and if documentation requirements for history and medical decision making are met and maximized:95 Guidelines:This would be a detailed examination (7 organ systems)The examination would meet criteria to bill a Level 3 New Patient or a Level 4 Established Patient97 Guidelines:This would be an expanded problem-focused examination (6 bullet points)The examination would meet criteria to bill a Level 2 New Patient or a Level 3 Established PatientE/M, Evaluation and management; ECG, electrocardiogram. Open table in a new tab Table VSteps for conducting a telemedicine visitArea of the allergy encounterComponent requiring educationPrevisitDetermine what visits are best suited for telemedicineEnsure that the patient has telemedicine platform accessEnsure that the patient and clinician have previsit planning and test calls to establishing secure remote and if needed, video connectionsDuring the visitObtain and document consentEnsure effective video communicationConduct physical examinationsOptimize privacy and data securityComplete orders, prescriptions, and patient instructionsPostvisitBill and codeCorrespond with PCPPCP, Primary care provider. Open table in a new tab E/M, Evaluation and management; ECG, electrocardiogram. PCP, Primary care provider. The utility of EMR integration can depend on the type of telemedicine that is employed. For remote monitoring telemedicine, there have been studies using patient-facing technologies to collect patient-generated health data that then flow into EMRs (such as peak flow or frequency of metered dose inhaler use).19Merchant R.K. Inamdar R. Quade R.C. Effectiveness of population health management using the propeller health asthma platform: a randomized clinical trial.J Allergy Clin Immunol Pract. 2016; 4: 455-463Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar,20Chan D.S. Callahan C.W. Sheets S.J. Moreno C.N. Malone F.J. An internet-based store-and-forward video home telehealth system for improving asthma outcomes in children.Am J Health Syst Pharm. 2003; 60: 1976-1981Crossref PubMed Scopus (114) Google Scholar Howev
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